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Interesting case #4 - 6 toes

Discussion in 'Foot Surgery' started by drsarbes, Jan 20, 2009.

  1. drsarbes

    drsarbes Well-Known Member


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    Following are X-rays of 8 y/o with supernumary digits.
    The patient has 6 toes on each foot, only the left has six metaheads.
    His complaint is pain in the sixth toe with shoes.
    As you can see from the soft tissue outline the sixth digit is somewhat of a
    macrodactyly with the fifth somewhat undersized.

    I do not have a photo of the foot itself, but I will take it pre operatively and
    post it here.

    Treatment option suggestions?

    Steve
     

    Attached Files:

  2. bob

    bob Active Member

    Probably the best result will come from a 6th toe amputation and removal of the lateral/ 6th metatarsal head. I guess the major problems with this could be that you could alter the growth plate of the 5th and you'd be leaving the boy with a small 5th toe, but it'd fit in the shoe, stop the pain and get him up and about relatively quickly.
    Another, more technically demanding option would be to remove the 5th toe, 5th metatarsal head and do an osteotomy to reduce the lateral bowing of the 6th metatarsal head. It's more surgery, not guaranteed to give a better result than the former and has all the risks of the other procedure and a few more.
    Any interdigital corns? Where's the pain coming from? Is it a rub on the shoe? I presume conservative care has been exhausted/ explored.
    Looking forward to the clinical photo.
     
  3. drsarbes

    drsarbes Well-Known Member

    Hi Bob:
    "Probably the best result will come from a 6th toe amputation and removal of the lateral/ 6th metatarsal head."

    That's what I'm planning. I'm more concerned with bone callus formation of the distal 1/3 of the 5th meta shaft after I remove the 6th metahead.

    Thanks again

    Steve
     
  4. Steve:

    Your surgical plan sounds very reasonable. I would be more concerned about a possible stress fracture after removal of the lateral-distal half of the 5th metatarsal shaft than bone callous formation. You may want to consider putting the patient in a cast or walking brace for 4-6 weeks after the case since the surgery will weaken the 5th metatarsal by making it more susceptible to bending moments from ground reaction forces acting on the 5th metatarsal head during weightbearing activities. Interesting case! Thanks for sharing.:drinks
     
  5. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    Good point.
    The patient is a rather "small" Asian 8 year old. Hopefully this will decrease the possibility of a stress fracture.
    I'll watch for it though
    Steve
     
  6. bob

    bob Active Member

    Yes, but there's not 100% chance of that happening, so I guess it's a wait and see job as ever. Same goes for the orthosis/ stress fracture thing. You'll have to get your resection just right to avoid not taking enough (leaving a prominence) or reducing width too much (Kevin's stress fracture) - bit of a Goldilocks procedure really, but there's nothing new there!

    Have you planned your incision yet? Be nice to see how you manage the flaps and the post op scar.

    Good luck with getting it 'just right'. Hope the little guy has a good return to normal. Like your post by the way - especially because you agreed with me! Ha haa. :drinks
     
  7. Dr. DSW

    Dr. DSW Active Member

    Steve,

    Interesting case. I would concur that the easiest route would be to simply amputate the 6th toe/most lateral toe and resect the lateral aspect of the 5th metatarsal. The growth plate may not be disrupted because it appears as if there are two articular surfaces.

    My concern would involve post operative hemostasis, since you are basically removing one cortical surface (the lateral cortex) and exposing medullary/cancelllous bone when you resect the lateral portion of the metatarsal. Naturally, this will result in bleeding and not the most structurally strong bone during the initial healing.

    (Remember the "old" days when we used bone wax?!)

    Therefore, as per Kevin's concern regarding a stress fracture, I would opt on the conservative side and probably keep this 8 y/o non-weightbearing for a few weeks.

    David
     
  8. drsarbes

    drsarbes Well-Known Member

    Here are the Digital photos I promised.
    The patient is scheduled for this week.
    Steve
     

    Attached Files:

  9. drsarbes

    drsarbes Well-Known Member

    OK:
    Intra op and a 1 week post op.
    The patient is doing very nicely.
    I'm happy with the cosmetic appearance.
    Steve
     

    Attached Files:

  10. drsarbes

    drsarbes Well-Known Member

    Last 2 pics 2 weeks post op.
    Doing very well.
     

    Attached Files:

  11. Gibby

    Gibby Active Member

    Wow.
    That looks fantastic.
    Excellent work.
    I have done 2 similar cases, but both patients were women in their 20's...
    I am sure you have made the patient and his parents very happy.

    Do you have him in a cast/CAM walker? NWB? Thank you for the pics-
    -John
     
  12. bob

    bob Active Member

    Nice work Steve.
    Well done. :cool:
     
  13. Hylton Menz

    Hylton Menz Guest

  14. drsarbes

    drsarbes Well-Known Member

    Hi John:

    Thanks.

    He was in a CAM walker for 3 weeks. He did not put any weight on the foot the first week although I told him it was OK. He was in a tennis shoe at three weeks.
    Kids..gotta love the way they heal.


    Dr. Menz: I'll try.

    Steve
     
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